ALBERT

Description: Nonphotosensitive trichothiodystrophy (TTDN) is a rare autosomal recessive disorder of neuroectodermal origin. The condition is marked by hair abnormalities, intellectual impairment, nail dystrophies and susce...

Description: Abstract Groundwater discharge delivering anthropogenic N from surrounding watersheds can impact lake nutrient budgets. However, upgradient groundwater processes and changing dynamics in N biogeochemistry at the groundwater‐lake interface are complex. In this study, seasonal water‐level variations in a groundwater flow‐through lake altered discharge patterns of a wastewater‐derived groundwater contaminant plume, thereby affecting biogeochemical processes controlling N transport. Porewater collected 15 cm under the lakebed along transects perpendicular to shore varied from oxic to anoxic with increasing nitrate concentrations (10‐75 μM) and corresponding gradients in nitrite and nitrous oxide. Porewater depth profiles of nitrate concentrations and stable isotopic compositions largely reflected upgradient groundwater N sources and N‐cycle processes, with minor additional nitrate reduction in the near‐surface lakebed sediments. Potential denitrification rates determined in laboratory microcosms were 10‐100 times higher in near‐surface sediments (0‐5 cm) than in deeper sediments (5‐30 cm) and were correlated with sediment carbon content and abundance of denitrification genes (nirS, nosZI, and nosZII). Potential anammox‐driven N2 production was detectable in deeper anoxic sediments. Injection of bromide and nitrite in the lake sediments showed that the highest net nitrite consumption rates were within the top 10 cm. However, short transit times owing to rapid upward pore‐water velocities (4‐5 cm h‐1) limited removal of the contaminant nitrate transiting through the sediments. Results demonstrate that local hydrologic and biogeochemical processes at the point of discharge affect the distribution and discharge rate of N through lakebed sediments, but processes in the upgradient groundwater can be more important for affecting N speciation and concentration.

Description: Background Langerhans cell histiocytosis (LCH) is a heterogeneous disease whose myriad manifestations result from accumulation of Langerhans cells in a variety of organs most commonly including skin, bone, central nervous system, liver, lymph nodes, and bone marrow. The disease can affect people of any age. Treatment is primarily driven by disease extent and organ involvement and can range from focused radiation or surgery to multi-agent chemotherapy. There is a relatively high recurrence rate following complete remissions with conventional chemotherapy. In the first-time-in-human (FTIH) study of the oral pan-AKT inhibitor afuresertib (GSK2110183), in patients with hematologic malignancies, a patient with refractory multi-system LCH experienced a prolonged period (〉 3 years) of clinical benefit on 125mg oral once daily afuresertib. This observation led to the evaluation of the use of afuresertib in patients with LCH. Methods This single-arm, open-label trial was designed to evaluate the efficacy and safety of afuresertib, administered at 125 mg once daily, in adults and adolescents with relapsed/refractory LCH and adults with treatment-naïve LCH. Secondary objectives included pharmacokinetics. Diagnosis of LCH was confirmed by pathology review of archival tissue. The Histiocyte Society criteria were used for response evaluation at three and six months with safety and pharmacokinetic assessments performed at pre-specified intervals. BRAF status from archival tissue was evaluated by Sanger sequencing. Results 17 patients (16 adults, 10 females) were enrolled; median age was 38 years (15-75). 3/17 patients had isolated pulmonary disease, 1/17 had single-system multifocal-bone disease, 1/17 had single-system skin disease, and 12/17 had multi-system disease. Seven patients were treatment-naïve; 10 had relapsed/refractory disease, including the one adolescent. The most frequent (〉20% of patients) adverse events (AEs), regardless of causality, were nausea (59%), fatigue (59%), upper respiratory infection (47%), diarrhea (47%), dyspepsia (35%), bone pain (39%), asthenia (24%), memory impairment (24%), decreased appetite (24%) and vomiting (24%). Most AEs were Grade 1 or 2 in severity; no Grade 4 AEs were reported and no Grade 3 AEs occurring in more than 1 subject were reported. 6/17 (35%) had afuresertib dose modifications (interruption or reduction). Afuresertib plasma concentrations in the adult patients were similar to values seen in adult patients with other hematologic malignancies in the FTIH study. Following a single dose, the concentration-time profile in the adolescent patient was similar to adults in the FTIH study (Tmax = 3h: Cmax 229 ng/ml: AUC24 = 3893 ng*h/mL). 15 patients had archival tissues collected for BRAF testing; 13 had DNA suitable for analysis. 2/13 was BRAF V600E mutant and 11/13 were BRAF wild type. Upon evaluation of the all-treated patient population, 5/17 (29%) patients were reported as better at the three and/or six month disease assessment. Among the 5 responders, three were treatment-naïve and two had relapsed/refractory disease. The median duration on study for all patients was 214 (44-426) days. For the 5 patients who responded, the median duration on study was 372 (255-426) days. Conclusion The pharmacokinetic and safety profile of afuresertib in patients with LCH was consistent with that observed in patients with other hematologic malignancies evaluated in the FTIH study. Afuresertib was active in patients with both treatment-naïve and relapsed/refractory disease. Additional evaluation, including molecular profiling, may be warranted alone or in combination with BRAF inhibitors or established therapies for LCH to determine the optimal population of patients with LCH who might benefit from afuresertib Disclosures: Vassallo: GlaxoSmithKline: Research Funding. Oliff:GlaxoSmithKline: Employment. Morris:GlaxoSMithKline: Employment. Reedy:GlaxoSmithKline: Employment. Portnoy:GlaxoSmithKline: Stock, prior employee Other. Smith:GlaxoSmithKline: Employment, Equity Ownership. Noble:GlaxoSmithKline: Employment, stock Other. Murnane:GlaxoSmithKline: Employment, stock Other. Szabo:GlaxoSmithKline: Employment. Heaney:Novartis: Research Funding; Sanofi-Aventis: Consultancy, Research Funding; Onconova: Research Funding; Incyte: Consultancy, Research Funding.

Description: Introduction: Ofatumumab is an anti-CD20 monoclonal antibody with single-agent responses of 47-58% in refractory CLL (Wierda et al 2010) and a median response duration ranging from 5.6-7.1 months. In order to improve upon these results, we combined ofatumumab with afuresertib, a pan-AKT kinase inhibitor. The AKT pathway plays a centralized role in tumor differentiation, migration, proliferation and survival and is frequently aberrantly activated in CLL (Longo et al 2007). Single agent afuresertib is very well-tolerated with minimal myelotoxicity in hematologic malignancies (Spencer et al ASH 2011). We present results from 27 of 31 planned patients (pts) in a trial of ofatumumab and afuresertib in relapsed/refractory CLL. Methods: Pts withCLL relapsed/refractory to at least one fludarabine-containing regimen were eligible. During the initial 6 month Treatment Phase, ofatumumab 2000mg IV was administered weekly for 8 doses, then once every 4 weeks for 4 doses (dose/schedule identical to the pivotal phase 2 trial) with afuresertib 125mg orally daily. An initial 10 day Lead-in Phase with afuresertib alone allowed for evaluation of pharmacodynamic (PD) and pharmacokinetic (PK) studies. Patients achieving SD, PR or CR by the end of the Treatment Phase proceeded to the Maintenance Phase with single-agent afuresertib for a maximum of 12 4-week cycles. Results: Demographics: Of the 27 patients enrolled, the median age was 63 yrs (range 43-76), absolute lymphocytes 60.4 x109 /L (range 1.0-464), β2M 5.1mg/L (range 1.1-16.6). High risk features included: FISH with del17p/del11q in 10 pts (37%), ZAP70+ in 20 pts (74%) and unmutated IgVH status in 18 pts (72%). The median number of prior therapies was 2 (range 1-6). Eleven pts (41%) were fludarabine-refractory but only 3 (11%) had received prior alemtuzumab. Toxicity: Hematologic: Gr 3-4 neutropenia occurred in 10 pts (37%) and thrombocytopenia (without bleeding) in 8 pts (30%) during at least 1 cycle of treatment. Only 1 pt (4%) developed febrile neutropenia. Nonhematologic toxicity: Most common toxicities (all grades) were infusion reactions (70%), upper respiratory infections (74%), dyspepsia (59%), cough (70%), and diarrhea (56%). Dyspepsia was temporally related to oral afuresertib and managed symptomatically. Of the 19 pts (70%) who had infusion reactions to the ofatumumab, only 3 were grade 3-4 (non-fatal, all cycle 1). Grade 3-4 non-infectious pneumonitis, attributed to ofatumumab, occurred in 3 pts (11%), with 2 pts requiring hospitalization. Two pts with preexisting atrial arrhythmias sustained exacerbation during weekly ofatumumab infusions. Most infections were mild, with grade 3 upper respiratory infections (2 pts), pneumonia (4 pts), and skin infection (1 pt). There were no grade 4 infections. Efficacy: The median number of study cycles was 8 (2-19). Of all 27 response-evaluable pts, 12 pts (44%) achieved a PR, 14 SD (52%), and 1 CR (4%) = overall response rate 48%. Response onset was rapid (median 1.4 mos). Nineteen pts did not complete treatment protocol due to: disease progression 12 pts (44%), toxicity 5 pts (19%), and patient preference 2 pts (7%). At a median follow-up of 9.5 mos, the median PFS is 8.6 mos (95% CI: 7.4-13.9) and OS not yet reached. PD Studies: CD19+ cells were assayed for phosphorylated AKT and downstream targets RAS40 and GSK3, in addition to phospho-proteins of alternative pathways including ERK and pS6 by multiplexed phospho-flow cytometry. Blood samples collected at screening demonstrated constitutive AKT phosphorylation. Partial inhibition of AKT signaling evidenced by increased phosphorylation of AKT and inhibition of GSK3 and/or RAS40 phosphorylation in response to BCR stimulation was observed post-treatment, indicating target engagement by afuresertib. PK Studies: Afuresertib exposure (Cmax and AUC) was similar when afuresertib was administered alone or in combination with ofatumumab. Conclusion: This phase 2 study of 27 previously treated CLL pts, 40% with fludarabine-refractory disease, demonstrates that the addition of an oral AKT inhibitor, afuresertib, to ofatumumab has anti-tumor activity and is generally well-tolerated with minimal myelotoxicity. Although this combination works rapidly with a response onset of 1.4 mos, the moderate response rate of 48% and PFS of 8.6 mos suggest that this combination may not provide significant benefit over single agent ofatumumab. Disclosures Chen: Glaxo Smith Kline: Honoraria; Lundbeck: Honoraria; Roche: Honoraria; Janssen: Honoraria; Sanofi: Research Funding; Celgene: Honoraria, Research Funding. Off Label Use: Afuresertib is not currently approved for use in CLL.. Trudel:BMS: Honoraria; Amgen: Honoraria, Speakers Bureau; Celgene: Consultancy, Equity Ownership, Honoraria, Speakers Bureau; GSK: Honoraria, Research Funding; Merck: Research Funding; Novartis: Consultancy, Honoraria.

Description: Introduction Ofatumumab is a novel anti-CD20 monoclonal antibody which led to impressive single-agent responses of 47-58% in a phase 2 study of CLL patients (pts) with refractory disease (Wierda et al 2010). Unfortunately, response durations were short (median 5.6-7.1 mos). In order to improve upon these results, we combined ofatumumab with a novel pan-AKT kinase inhibitor, afuresertib (GSK2110183). The AKT pathway plays a centralized role in tumor differentiation, migration, proliferation and survival and is frequently aberrantly activated in CLL (Longo et al 2007). Single agent afuresertib is very well-tolerated with minimal myelotoxicity in relapsed/refractory hematologic malignancies (Spencer et al ASH 2011). We present an interim analysis of the initial 19 of 31 planned pts in an ongoing trial of ofatumumab and afuresertib in relapsed/refractory CLL. Methods Previously treated CLL pts who have received at least one prior fludarabine-containing regimen with disease progression are eligible. During the initial 6 month Treatment Phase, ofatumumab 2000mg IV is administered weekly for 8 doses, then once every 4 week cycle for 4 doses (dose/schedule identical to the pivotal phase 2 trial) with afuresertib 125mg orally daily. An initial 10 day Lead-in Phase with afuresertib alone allows for evaluation of pharmacodynamic (PD) changes in phosphoproteins and pharmacokinetic (PK) studies. Pts are assessed for safety and response on day 1 of each cycle. Pts achieving SD, PR or CR by the end of the Treatment Phase proceed to the Maintenance Phase with single-agent afuresertib for a maximum of 12 mos (12 cycles). Results Demographics: To date, 19 pts have been enrolled. Median age is 65 yrs (range 43-76), baseline median Hb 108g/L (range 80-145), absolute lymphocytes 29.7 x109/L (range 1.0-464.9), β2M 4.42mg/L (range 1.42-3.21), bulky nodes ≥5cm in 5 pts (32%), organomegaly in 8 pts (42%), del17p/del11q on FISH in 9 pts (47%), and ZAP70+ in 13 pts (68%). Eight pts (42%) were fludarabine-refractory; only 2 pts had received prior alemtuzumab. The median number of prior therapies was 2 (range 1-6). Toxicity: Hematologic: 4 pts (21%) developed Gr 3-4 neutropenia during at least 1 cycle; 1 pt (5%) had a febrile neutropenia event. Only 2 pts (10.5%) have developed Gr 3-4 thrombocytopenia, without bleeding. Nonhematologic toxicity: Most common related grade 3-4 toxicities were GI: dyspepsia (53%), diarrhea (37%), nausea (21%), temporally related to oral afuresertib and easily managed symptomatically. Infusion reactions to ofatumumab were frequent (12 pts; 63%) with grade 3 reactions in 3 pts. Five pts (26%) developed non-infectious pneumonitis, with 3 pts requiring hospitalization. Two pts with preexisting atrial arrhythmias sustained exacerbation with weekly ofatumumab infusions. Most infections were mild, with only 1 grade 3 cellulitis. Efficacy: Of the 19 response-evaluable pts receiving a median of 6 cycles (range 1-9), 8 pts (42%) have achieved a PR, 11 SD (58%), and no CR. Response onset was rapid at a median 0.9 mos (range 0.8-2.8). At a median follow-up of 6.8 mos (range 0.3-12.9 mos), 5 pts (26%) have progressed and one patient has died after cycle 1 on therapy due to progressive CLL. PD Studies: CD19+ cells are assayed for phosphorylated AKT and its downstream targets RAS40 and GSK3 in addition to phospho-proteins of alternative pathways including ERK and pS6 by multiplexed phospho-flow cytometry. Peripheral blood samples are collected at screening and on cycle 1 day 10, after dosing with afuresertib. Of the 7 patients evaluated thus far, 5 demonstrated constitutive AKT phosphorylation at baseline. Partial inhibition of AKT signaling evidenced by increased phosphorylation of AKT and inhibition of GSK3 and/or RAS40 phosphorylation in response to BCR stimulation was observed post-treatment, indicating target engagement by afuresertib. PK Studies: Afuresertib exposure (Cmax and AUC) was similar when afuresertib was administered alone or in combination with ofatumumab. Conclusion Preliminary results from this phase 2 study suggests that a combination of ofatumumab plus a novel oral AKT inhibitor, afuresertib, has activity in previously treated CLL and is generally well-tolerated with minimal myelotoxicity. Response data are encouraging but whether durable responses can be achieved requires more mature follow-up. Disclosures: Chen: Johnson & Johnson: Consultancy, Research Funding; Lundbeck: Consultancy; Celgene: Consultancy, Research Funding; GlaxoSmithKline: Research Funding; Roche: Honoraria. Off Label Use: Off-label use of ofatumumab and afuresertib for the treatment of relapsed/refractory CLL. Smith:GSK: Employment, Equity Ownership. Johnston:Roche: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Lundbeck: Membership on an entity’s Board of Directors or advisory committees, Research Funding; GSK: Membership on an entity’s Board of Directors or advisory committees, Research Funding.

Description: Key Points Afuresertib has a favorable safety profile with manageable side effects and demonstrates single-agent activity against hematologic malignancies. Inhibition of AKT with afuresertib may provide a novel therapeutic strategy for hematologic malignancies, especially for multiple myeloma.